Table of contents
An unexpected question from one of my patients forced me to raise this topic. Woman 50+, beautiful, looks young. Menstruation is absent for several months. By all indications – menopause. We consider the indications and contraindications for the appointment of menopausal hormone therapy, and suddenly the question: “Is that all, the end?” There will be no more sex in my life?”
“From what? – I wonder. – In some sense, life is just beginning. You can no longer worry about contraception, feel free…”
“So if you don’t need pregnancy, why have sex? And then, this terrible discomfort and dryness, like in the desert… just torture. I can’t wait when I can officially “retire,” the woman explained.
✓ What processes in a woman’s body lead to similar sensations and cause a storm of negative emotions at the mere mention of sexual intercourse?
✓ Why can symptoms of dyspareunia (pain and discomfort during sexual intercourse) occur not only in women in menopause, but also long before its onset, for example, after childbirth?
✓ How to maintain the health of mucous membranes and not “retire” at any age?
Hormones are the main conductors of all processes in our body, including sexual behavior and the health of the genitourinary system. They are responsible for sexual desire, control the thickness and moisture of the mucous membranes of the urogenital tract, the amount of collagen and elastin in them, the saturation of blood vessels, the composition of the female microflora, the pH of vaginal secretions, and their smell.
At the onset of natural, physiological menopause, the level of sex hormones decreases several times: estrogens decrease by approximately 10 times, testosterone and androstenedione by 2 times, and the level of DHEA and its sulfate decreases by 2-3 times. Early surgical menopause makes the situation even more catastrophic.
Deficiency of sex hormones leads to dystrophic changes in the urogenital tract, which causes a number of negative symptoms, such as thinning and dryness of mucous membranes, frequent inflammatory diseases of the vagina, urethra and bladder, urinary incontinence when coughing, sneezing or jumping, dissatisfaction with sex.
Structural changes of the genitourinary system in menopause
ANDROGEN DEPENDENTS
- reduction of collagen and hyaline
- decrease in elastin, loss of elasticity
- trophic and functional changes in muscle tissue
- decrease in vaginal blood flow
- development of connective tissue of the introitus
- decrease in the volume of the labia
- retraction (expansion) of the entrance to the vagina
- protruding and vulnerable urethra
ESTROGEN DEPENDENT
- the thickness of the mucous membrane
- decrease in humidity
- increased pH of the vagin
(S.R.Davis et al, 2015)
As can be seen from this table, most of the changes are related to the influence of androgens, not estrogens, which is not surprising. Studies have shown that androgen receptors are located throughout the genitourinary tract, and the largest number of them are in the labia majora and labia minora, the vestibule of the vagina, and the three layers of the mucous membrane.
Hormone-deficiency conditions and related phenomena of dyspareunia and genitourinary dysfunction can occur in women of reproductive age with some autoimmune and endocrine diseases, menstrual cycle disorders, against the background of combined hormonal contraceptives (COCs), in the postpartum period. In all cases, there will be a decrease in the level of sex hormones or a change in the sensitivity of receptors to these hormones.
The most effective method of treating vaginal atrophy in menopause is local hormone therapy with estrogens and/or androgens. For example, local application of DHEA, which is a precursor to both estrogens and androgens, acts on every cell and component of the vaginal wall, vaginal vessel walls and nerve endings, restores vaginal pH and microflora, and has no restrictions in contraindications to estrogens.